Compensation for utilization management activities a. Consistent with 42 CFR §438.3(i) and 42 CFR §422.208, compensation to individuals or entities that conduct utilization management activities shall not be structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any beneficiary.
Compensation for utilization management activities. Compensation to individuals or entities that conduct utilization management activities cannot be structured so as to provide incentives for the individual or entity to deny, limit, or discontinue Medically Necessary services to any Enrollee.
Compensation for utilization management activities. Each contract must provide that, consistent with 42 CFR, Sections 438.6(h) and 422.208, compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any member.
Compensation for utilization management activities. Should the CONTRACTOR have a subcontract arrangement for utilization management activities, the CONTRACTOR shall ensure, consistent with 42 CFR 438.210(e) that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any enrollee, as provided by the Balanced Budget Act of 1997 and the provisions of 42 CFR 438.210(e).
Compensation for utilization management activities. The Parties agree that the compensation to be paid to Subcontractor pursuant to Exhibit B hereto does not, and shall not be construed to, directly or indirectly provide incentives to individuals or entities conducting utilization management activities to deny, limit, or discontinue Covered Services to any Member in accordance with 42 CFR § 438.210(e). Furthermore, Subcontractor is prohibited, through the use of incentives, direct or indirect payments, or other practices (including but not limited to incentives in the form of compensation to individuals or entities that conduct Subcontractor‘s utilization management activities), from denying, limiting or discontinuing medically necessary services to any Member. Subcontractor is further required to comply with all applicable regulations related to physician incentive contracts.
